Article Date: 12/1/2012

DISCUSSING DRY EYE DISEASE images

Discussing Dry Eye Disease

Effectively managing this disease is contingent on strong patient communication.

ERNIE BOWLING, O.D. M.S., F.A.A.O., DIPL. Gadsden, Ala.

Communicating your findings and treatment plans to your dry eye disease patients is paramount: For the patient must understand what you’ve found and what you’ve planned to fully accept their condition and your prescribed therapy.

“The most important aspects for caring for patients with dry eye are to educate them about the chronic nature of the disease process and to provide specific instructions for therapeutic regimens,” says the dry eye syndrome guidelines of the U.S. Department of Health and Human Services agency for healthcare research and quality.1

Here, I discuss how to provide effective communication to these patients.

1 Keep it simple and brief.

I’ve found that the following three-steps and accompanying scripts have enabled me to instill patient compliance to my prescribed treatment. These scripts provide easy-to-understand explanations.

Explain the condition in layman’s terms. “A lack of tears, improper lubrication, or tears draining too quickly from the eye result in dry eye disease. Men and women of any age can be affected, however, during pregnancy and after menopause women are especially susceptible, due to hormonal changes that affect the tear film. Dry eye disease can also cause excessively watery eyes as a result of your tears lacking the proper balance of mucous, water and oil to coat the eyes properly. In this case, the eye sends a distress signal through the nervous system to the brain for more lubrication. In response, the brain tells the tear gland to flood the eye with tears to try to compensate for the underlying eye dryness. However, these tears are mostly water, and do not have the lubricating qualities or the rich composition of normal tears. They wash debris away, but they do not coat the eye surface properly.”

Discuss how treatment options work. “Though dry eye disease cannot be cured, a number of steps can be taken to treat it. There are several prescription medications we may have to use, but let’s begin with a simple tear substitute. Tear substitutes work to replenish your lack of tears. These artificial tears are available over the counter.

Sometimes, it is necessary to close the ducts that drain tears from the eye, much like placing a stopper in a drain, to provide relief. This may be done with a removable plug or one that dissolves through a few days. The plug is inserted into the tear drain of the lower eyelid to determine whether permanent plugs can provide an adequate tear supply. If temporary tear drain plugging works well, longer-lasting plugs may be used. This will hold tears around the eyes to improve lubrication. The plugs can be removed if necessary.”

(I often briefly discuss punctal plugs in case they are needed later. In other words, I like to give patients a heads up of what could be coming.)

American Academy of Ophthalmology Patient Education Recommendations

The American Academy of Ophthalmology recommends the following4:

► Counsel patients about the chronic nature of dry eye and its natural history.

► Provide specific instructions for therapeutic regimens. (Emphasis added)

► Reassess periodically the patient’s compliance and understanding of the disease, risk for associated structural changes and realistic expectations for effective management, and reinforce education. (Emphasis added)

► Refer patients who have manifestations of a systemic disease to an appropriate medical specialist.

► Caution patients who have pre-existing DED that keratorefractive surgery, particularly LASIK, may worsen their dry eye condition.

Explain the lack of correlation between symptoms and signs. “Often times with dry eye disease, there is a lack of a correlation between the patient’s symptoms and their clinical signs. As a result, your eyes may feel good, though the clinical signs tell another story, or vice versa. Because untreated, chronic dry eye can lead to damage of the eye’s surface, an increased risk of eye infections, eventually lead to an inability to produce tears and even damage your vision, it’s imperative you inform me when your eyes start to feel worse and that you follow the treatment schedule I’ve prescribed regardless of whether your eyes feel better.” (See “American Academy of Ophthalmology Patient Education Recommendations,” below.)

While you may choose to delegate some of this script to your staff, personally handle the initial discussion of your findings. Personally addressing your patients’ concerns is essential for treatment acceptance and success. This is because you, as the eye-care professional, are the expert. Finally, tell the patient you’ll be able to provide him/her with early as well as future care if their dry eye disease progresses. This message is crucial, as it helps persuade him/her to return for further care and, perhaps, refer others.

2 Provide back-up information.

Providing the patient with written information is vital when explaining any diagnosis. The reason: The moment patients are told they have any disease, their initial shock often precludes them from processing most verbal information. Also, studies reveal that patient retention of information is improved with the addition of written information during the consultation process.2 In fact, one study shows 80% of patients whose dry eye treatment failed on a first trial were successful in a second trial as a result of proper patient education.3

I’ve found that charts and illustrations work best, as pictures are worth a thousand words. In my practice, I provide patients a practice-created handout of their particular condition for them to take home. The handout reinforces what I’ve said to the patient as well as answers any questions he/she may have after leaving the office. Too much information can overwhelm most patients, and too little leads to more questions later by phone. A one-page handout seems to be just about the right amount of information for most patients.

Many practices have developed their own dry eye patient education materials, and those can be found online. The Department of Veterans Affairs (www.va.gov/optometry/docs/Patient_Education-Dry_Eye_Syndrome.doc) has an excellent dry eye patient education handout. Likewise, the National Eye Institute has a dry eye facts page (www.nei.nih.gov/health/dryeye/dryeye.asp), as does the American Optometric Association (www.aoa.org/dry-eye.xml). Also, dry eye treatment manufacturers offer material.

The key

The key to improving the DED patient’s symptoms, and therefore, quality of life, is effective communication. After all, as illustrated above, doing so increases the patient’s likelihood of complying with your therapy. And happy patients make for successful doctors. OM

1. Agency for Healthcare Research and Quality. Guideline Summary: Dry eye syndrome. Limited revision. Available at: www.guidelines.gov/content.aspx?id=36094.(Accessed 10/14/2012).

2. Hong P, Makdessian AS, Ellis DA, et al. Informed consent in rhinoplasty: prospective randomized study of risk recall in patients who are given written disclosure of risks versus traditional oral discussion groups. J Otolaryngol Head Neck Surg. 2009 Jun;38(3):369-374.

3. HighBeam Research. www.high beam.com/doc/1P3-2408128631.html. Charters L. Education key to dry eye therapy. Ophthalmology Times, July 15, 2011.

4. American Academy of Ophthalmology. Dry eye syndrome summary benchmarks for preferred practice pattern guidelines, American Academy of Optometry, October 2011. http://one.aao.org/CE/PracticeGuidelines/SummaryBenchmark.aspx?cid=fdd/d69c-adf0-4910-916b-9623395c8305. (Accessed 10/13/2012).

images

Dr. Bowling is in private optometric practice in Gadsden, Ala. He is a Primary Care Diplomate of the American Academy of Optometry and author of Optometric Management’s Managing Dry Eye eNewsletter. E-mail him at drbowling@windstream.net. Or send comments to optometricmanage ment@gmail.com.



Optometric Management, Volume: 47 , Issue: December 2012, page(s): 34 35 36